Lincoln Villa.
Lincoln Villa is Ranked in the bottom 2% of California memory care with 21 CDSS citations on record; last inspected Jul 2025.
Memory Care Residential Facility in Fremont Since 1976, reviewed on public record.
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Compared to 61 California facilities with a similar number of beds.
RCFE memory care · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
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Lincoln Villa has 21 citations on record. Know the moment anything changes.
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Citation history, plotted month by month.
21 deficiencies on record. Each bar is a month with a citation.
Finding distribution
20 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour
“Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Lincoln Villa's record and state requirements.
State records show 3 Type A deficiencies — citations indicating actual harm to residents — can you describe what each citation involved and what corrective actions were taken?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Fourteen complaints have been filed with CDSS during the inspection period on file — what were the nature of these complaints, and how many were substantiated by investigators?
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Lincoln Villa was cited under §87705 or §87706 for dementia care requirements — what specifically was cited, and what changes were made to address the deficiency?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every inspection visit, verbatim.
14 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-07-08Complaint InvestigationMixedType B · 1 finding
Plain-language summary
This was a complaint investigation at the facility. Investigators found that staff improperly removed residents' medications and hygiene products from their rooms, including prescribed items that residents were allowed to keep by their doctor's orders, and this violation was substantiated. A separate allegation that staff failed to change residents' diapers promptly could not be proven and was not substantiated.
“Based on interviews, the licensee did not comply with the section cited above when staff removed R1's hygeine and prescription items which poses a potential personal rights risk to person in care.”
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Continue from LIC9099.. Interview with R1 indicated that staff took R1’s hygiene products from their room that includes prescription items. Interviews with R2, R3, and R4 revealed that staff took belongings such as medications and supplies to place in a locked cabinet in their rooms. R1 confirmed that they received an item back, but not their prescribed item. Interview with Administrator (ADM) on 06/04/2025 revealed there is a facility policy to have a written physician’s order that explains that residents are allowed to have medications stored their room. A review of the facility policy on Medication Storage and Bedside Authorization on 06/04/2025 stated that residents can keep medications at their bedside if there is a written physician’s order that states that the residents need to for their care. However, a review of R1’s physician’s report dated 03/25/2025 showed that R1 is able to store prescription and PRN medications. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted with Administrator. A copy of this report and appeal rights provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continue from LIC9099-A... During the initial visit on 04/23/2025, LPA toured the facility and did not observe any residents smelling of urine or in soiled undergarments. Interview with R1 stated that staff would not change their diapers and leave them soaked. 2 out of the 4 residents revealed that staff would assist them in diaper changes when needed and on their scheduled times. 1 out of the 4 residents interviewed can toilet on their own and stated that they do not need assistance with diaper change. Staff interviews revealed that they would check on the residents during their first round of the shift, every 2 hours after that, and as needed. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation are unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator.
2025-06-06Other VisitType B · 1 finding
Plain-language summary
On June 6, 2025, inspectors visited the facility to investigate a self-reported incident from May 31 in which a resident with dementia left the facility without staff awareness and was later found by police and taken to the hospital after a fall. The resident had removed their GPS tracking bracelet before leaving, and staff followed protocol by calling 911 when they could not locate them. A violation was cited for failure to maintain adequate safeguards to prevent residents at risk of wandering from leaving the facility unsupervised.
“The licensee did not comply with the section cited above by not providing supervision causing R1 to AWOL from the facility which posed a potential health and safety risk to resident in care.”
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On 06/06/2025 at 9:15 AM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that occured on 05/31/2025. Administrator self-reported the incident on 06/01/2025. LPA met with Administrator (ADM), Divine Fernandez, and explained the purpose of the visit. LPA received an incident report from the facility that indicated Resident 1 (R1) went AWOL. The facility staff was informed by R1's sister that the resident was seen outside of the facility. R1 was found by the police and escorted to the hospital for post fall. R1 returned to the facility later on that day. During the visit, LPA reviewed R1's Physician's Report dated 08/19/2024 that showed that R1 has a diagnosis of dementia and is unable to leave the facility unassisted. Interviews with ADM and Staff 1 (S1) indicated that residents with dementia has two bracelets such as a GPS tracker and one that will alarm when a resident is in close proximity of the exit doors. The GPS tracker revealed that R1 was still at the facility during that time. However, staff discovered later on that R1 took their GPS tracker off and placed it in the dining hall. S1 stated that they contacted 911 to follow their facility protocol for elopement when they were unable to locate R1. LPA attempted to interview R1, however, R1 does not recall the incident. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights and a copy of this report provided.
2025-05-30Complaint InvestigationSubstantiatedType B · 1 finding
Plain-language summary
An investigation found that the facility failed to file a required report to the state Ombudsman about an incident between two residents on March 22, 2025. Staff members confirmed they verbally reported the incident and recorded it in a log, but did not complete the formal written report that regulations require. The facility was cited for this violation.
“Based on observation, the licensee did not comply with the section cited above by not reporting to the local ombudsman which poses a potential health and safety risk to residents in care.”
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Continue from LIC9099... Based on interviews conducted on 04/17/2025 and 05/30/2025, ADM confirmed with LPAs that the facility did not submit an SOC 341 to Ombudsman regarding the incident that occurred on 3/22/2025 between R1 and R2. All staffs that LPAs interviewed stated that all unusual incidents get verbally reported to the supervisor and then recorded in the communication log. However, staff admitted to not having completed an SOC 341. The above allegation is substantiated. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted with Fernandez. Appeal rights and copy of this report provided.
2025-05-07Annual Compliance VisitType A · 2 findings
Plain-language summary
During a pre-licensing inspection on May 7, 2025, inspectors found that antacid tablets were left unlocked in a resident's room and cleaning wipes were left unlocked and accessible to residents in the front office. The facility must submit proof of correction. Repeat violations within twelve months could result in additional penalties.
“Based on observation, the licensee did not comply with the section cited above by having TUMS unlocked in a drawer in room #43 which poses an immediate health and safety or personal rights risk to persons in care.”
“Based on observation, the licensee did not comply by having Lysol wipes in the front office unlocked and accessible to residents which poses an immediate health and safety risk to the residents in care.”
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On 05/07/2025 at 3:35 PM, Licensing Program Analyst (LPA) P.Manalo arrived to do a Case Management visit. LPA met with the Administrator, Divina Fernandez, and explained the purpose of the visit. While at the facility for a pre-licensing, LPA observed the following deficiencies: At 1:30 PM, LPA observed TUMS unlocked in a drawer in room #43. At 3:00 PM, LPA observed Lysol wipes in the front office unlocked and accessible to residents. Deficiencies is cited from Title 22 California Code of Regulation (see 809D). Failure to submit proof of corrections and any repeat violation within twelve-month period may result in additional civil penalties. Exit interview conducted. Appeal Rights, and copy of this report.
2025-03-20Other VisitType A · 2 findings
Plain-language summary
During a pre-licensing inspection on March 20, 2025, inspectors found medications stored unsecured in three resident rooms and cleaning supplies stored in two resident rooms, creating potential access hazards. The facility was cited for these storage violations and given time to correct them. Failure to fix these issues or repeat violations within a year could result in additional penalties.
“Based on observation, the licensee did not comply in having the Med cart unlocked, and medications were found in Room #3, Room #15, and room #31.”
“Based on observation, the licensee did not comply in having Lysol Cleaning wipes in Room #26 and shower grease spray, deep cleaning spray in Room #15 which poses a potential health and safety risk to the residents in care.”
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On 03/20/2025 at 1:13 PM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen while at the facility for a pre-licensing observed the following deficiencies: At 10:50 AM, LPA observed the Med cart unlocked, and medications were found in Room #3, Room #15, and room #31. At 12:00 PM, LPA observed Lysol Cleaning wipes in Room #26 and shower grease spray, deep cleaning spray in Room #15. Deficiency is cited from Title 22 California Code of Regulation (see 809D). Failure to submit proof of correction and any repeat violation within twelve-month period may result in additional civil penalties. Exit interview conducted. Appeal Rights, and copy of this report provided via e-mail.
2025-02-12Complaint InvestigationMixedNo findings
Plain-language summary
A complaint investigation found that the facility failed to provide a resident with monthly billing statements and payment information at admission—staff mailed invoices to an outdated address on file and the resident never received them at the facility. A second allegation that the facility did not obtain a responsible party's signature on the admission agreement was not substantiated, as the resident signed the agreement themselves. The facility was cited for the billing documentation violation.
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LIC9099-C (Page 2) Allegation: Licensee did not provide resident of monthly fees upon admission. Finding: Substantiated On 02/12/2025 LPA interviewed W (W1). W1 stated that Resident (R) R1 never received any documents on the payments and due dates. W1 stated that R1 became aware of unpaid payments in mid Oct/Nov '24. LPA interviewed Staff (S). S1 and S2 stated that billing invoices were mailed monthly to R1's home address on file and that they also hand delivered a copy to R1 at the facility. S1 and S2 stated that the mailed billing statements were being returned back undelivered. LPA interviewed R1 that stated that they never received any billing statements while at the facility. R1 stated that they do not remember receiving billing invoices and that they have not received anything monthly directly from the facility. R1 stated that the address on file is where they lived 2 years ago and that their family does not live at that address anymore. Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted with Divine Fernandez. Appeal rights and copy of this report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC9099-C (Page 2) Allegation: Licensee did not obtain signature of resident’s representative on admission agreement. Finding: Unsubstantiated On 02/12/2025 LPA interviewed W (W1). W1 stated that Resident (R1) does not have an Responsible Party and that R1 is his own self responsible party financially. LPA interviewed R1 and R1 stated that they are the only person that signed the admission agreement. LPA reviewed R1's admission agreement documents and all documents obtained included R1's signatures. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
2024-12-04Other VisitType A · 3 findings
Plain-language summary
A routine case management inspection found that the facility had broken storage in the courtyard containing garden shears and a rake, cleaning supplies and personal care items stored in resident rooms, an unlocked housekeeping storage room, and a strong odor of urine in the hallway and activity area. The inspector reviewed staff and resident files, checked food supplies and the medication room, and interviewed residents and staff. The facility was cited for violations and given a deadline to submit corrections.
“-Based on observation, the licensee did not comply with the section above in unlocked peritoneal cleanser and shaving cream which pose an immediate health and safety risks to persons in care.”
“-Based on observation, the licensee did not comply with the section above in broken storage where rake and garden shears are kept and housekeeping room unlocked which pose an immediate health and safety risks to persons in care.”
“-Based on observation, the licensee did not comply with the section above in strong smell of urine in the hallway and activity area which pose a potential rights risk to persons in care.”
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Licensing Program Analyst (LPA) Delmundo conducted a case management inspection to ensure the facility is in compliance with applicable statutes and regulations and ensure the health and safety of residents. LPA met with Divina Fernandez, administrator (ADM), and informed the reason for visit. LPA conducted a tour of the physical plant with the ADM. Food supplies were checked and observed good for 2 days of perishables and 7 days of non-perishables. During the visit, the LPA conducted interviews with residents, staff and the administrator. Licensees are not on-site and not available for interview. LPA reviewed staff and resident files and checked the medication room. LPA observed the following: -at 2:45 pm, garden shears and rake in a broken storage in the courtyard. -at 2:52 pm to 3:15 pm, peritoneal cleanser, shaving cream in the residents rooms. -at 3:05 pm, unlocked housekeeping room where cleaning supplies are kept. -strong smell of urine in the hallway and activity area. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with ADM. An exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and a copy of the report provided.
2024-06-07Complaint InvestigationSubstantiatedType B · 2 findings
Plain-language summary
This complaint investigation found two substantiated safety problems at the facility. One resident with dementia was wandering into other residents' rooms at night and disturbing them, and staff told residents to lock their doors rather than addressing the behavior; staff also acknowledged the resident's nighttime wandering worsened after a medication for sleep and behavior problems was stopped at the family's request due to weight gain concerns. A second resident with oxygen in their bedroom was found smoking cigarettes and possessing a lighter in their room—a fire hazard—though the facility stated it has since implemented a policy requiring staff to supervise smoking only in a designated outdoor courtyard area where the resident must hand over portable oxygen to staff.
“Based on interview and record review, the licensee did not comply with the section cited above by not having cigarettes and lighters inaccessible to R2 while oxygen in use inside which poses an immediate health and safety risk to persons in care.”
“Based on interviews andrecord review, the licensee did not comply with the section cited above by not having which poses an immediate health, safety and personal rights risk to persons in care.”
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LIC809-C Continued... Allegation: Staff did not provide a comfortable environment for resident. Substantiated. On 06/06/2024 LPA spoke to RP who stated that R1 is wandering at night and early in the morning disturbing other residents. RP stated that R1 opened their bedroom door and came into their room. RP stated that the staff said that they couldn't do anything and to lock their doors. LPA interviewed S1 that stated that R1 has Dementia and they are aware of R1 walking at night, going into other residents' rooms, banging on the doors and the behavior. LPA interviewed S2 that stated that R1's behavior changed when they discontinued the medication that was helping the insomina and resident's behavior. S2 stated that R1's son wanted the medication stopped because R1 was gaining weight and was eating more food. Allegation: Resident smokes while using oxygen. Substantiated. On 06/06/2024 LPA spoke with RP who stated that R2 was smoking cigarettes in their own bedroom while they have oxygen in R2's bedroom. RP stated that R2 shares room with another resident (R3). RP stated that R2 came to them asking for a cigarette lighter. RP stated that R2's room is across the hall. RP stated that they do not feel safe due to R2 smoking and also having a lighter in the their possession while oxygen is in use in the bedroom. LPA interviewed S1 that stated about 2-3 weeks ago, the caregivers did find cigarettes and a lighter in R2's bedroom. S1 stated that one of the Med Techs saw a cup and smelled a cigarette and that is when they found the cigarette. S1 stated that on that day R2 wasn't on their baseline and seemed confused. S1 stated that R2 was transported to the hospital for shortness of breath. S1 stated that R2 returned back to the facility with a hospice order. LPA interviewed S2 that stated that the incident was discussed by the supervisor and that staff is suppose to monitor that R2 doesn't get any more cigarettes and lighters. LIC9099-C Continued... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC9099-C Continued... S2 stated that R2 can smoke in the courtyard area which is designated for smoking. S2 stated that when R2 wants to smoke they have to come to the Med Tech room and hand over the portable oxygen and then the Med Techs will give R2 a cigarette and lighter. S2 stated that there is always a caregiver with R2 when they smoke a cigarette in smoking area. LPA called and interviewed S3 that stated R2 does not smoke in their room and that they have not seen any cigarettes. Based on LPA's observations, and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted with Administrator. Appeal rights and copy of this report was provided.
2024-03-24Other VisitType A · 8 findings
Plain-language summary
During a routine annual inspection on March 24, 2024, inspectors found that the facility was missing required medical documentation for residents (current medical assessments, care plans, and tuberculosis test results for some residents) and had staffing issues including one staff member who was not fingerprint cleared and worked at the facility without criminal background clearance, staff lacking current first aid training and health screenings, and incomplete staff training records. The facility also could not provide a prescribed medication for one resident and had not documented completion of required disaster drills. The facility was assessed a $500 civil penalty for the fingerprint clearance violation, and the non-cleared staff member was required to leave immediately.
“Based on record review, the licensee did not comply with the section cited above by not having S4 fingerprint cleared prior to working at the facility which poses an immediate health and safety risk to persons in care. POC Due Date: 03/25/2024 Plan of Correction 1 2 3 4 Administrator asked S4 to leave the facility during inspection. Administrator will follow up with Guardian regarding S4's fingerprint clearance and submit communication to CCLD by POC date. Civil penalty of $500 is being assessed.”
“Based on observation and record review, the licensee did not comply with the section cited above by not having R3's medication available which poses an immediate health and safety risk to persons in care. POC Due Date: 03/25/2024 Plan of Correction 1 2 3 4 Administrator has agreed to obtain R3's medication or obtain a discontinue order from the doctor. Administrator will submit communication or picture of medication to CCLD by POC date.”
“Based on record review, the licensee did not comply with the section cited above by not having current medical assessment for two residents and not having current reappraisals for five residents which poses a potential health and safety risk to persons in care. POC Due Date: 04/19/2024 Plan of Correction 1 2 3 4 Administrator has agreed to obtain current medical assessment for R1 and R2 and obtain current reappraisals for R1, R2, R3, R4, and R5. Administrator will submit the documents to CCLD by POC date.”
“Based on record review, the licensee did not comply with the section cited above by not having TB test for R3 which poses a potential health and safety risk to persons in care. POC Due Date: 04/19/2024 Plan of Correction 1 2 3 4 Administrator has agreed to obtain R3's TB test results and submit a copy to CCLD by POC date.”
“Based on record review, the licensee did not comply with the section cited above by not having current First Aid training for two staff which poses a potential health and safety risk to persons in care. POC Due Date: 04/19/2024 Plan of Correction 1 2 3 4 Administrator has agreed to obtain current first aid training for S3 and S4 and submit copies of completion to CCLD by POC date.”
“Based on record review, the licensee did not comply with the section cited above by not having health screening and TB test for two staff which poses a potential health and safety risk to persons in care. POC Due Date: 04/19/2024 Plan of Correction 1 2 3 4 Administrator has agreed to obtain health screening and TB test results for S3 and S4 and submit copies to CCLD by POC date.”
“Based on record review, the licensee did not comply with the section cited above by not having current annual training for S5 which poses a potential health and safety risk to persons in care. POC Due Date: 04/19/2024 Plan of Correction 1 2 3 4 Administrator has agreed to obtain and submit current annual training for S5 to CCLD by POC date.”
“Based on record review, the licensee did not comply with the section cited above by not having disaster drill log which poses a potential health and safety risk to persons in care. POC Due Date: 04/19/2024 Plan of Correction 1 2 3 4 Administrator has agreed to conduct disaster drill and submit disaster drill log to CCLD by POC date.”
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On 3/24/2024 at 9:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with LVN, Leah Agron and explained the purpose of the visit . Administrator, Divina Fernandez arrived an hour and a half later. The facility’s fire clearance was approved for 76 non-ambulatory residents of which 76 may be bedridden and 10 residents may be under hospice care. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication carts and medication room. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 8/8/2023. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility purchase food once a week. Freezer temperature was measured at -20 degrees F and the refrigerator was measured at 40 degrees F. Hot water temperature was measured at 115.7 degrees F in a resident's bathroom sink. Grab bars for each shower and toilet were installed. Non-skid mats were observed. There were adequate lights in each room. Indoor and outdoor passages were free of obstruction. LPA reviewed 5 resident records and 5 staff records starting at 10:50AM. LPA conducted interviews with 4 residents and 4 staff during inspection. LPA also reviewed a sample of resident's medications and MAR (Medication Administration Record). At 11:30AM, LPA observed R1 and R2 does not have current medical assessment on file. R1, R2, R3, R4, and R5 does not have current needs and service plans on file. At 11:45AM, LPA observed R3 does not have TB test results on file. (Continue on LIC809C...) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 At 11:55AM, LPA observed S4 is not fingerprint cleared. LPA checked on Guardian website to verified that S4 does not have criminal record clearance. S4 left the facility and will not return to the facility until fingerprint cleared. Civil penalty of $500 is being assessed. At 12:10PM, LPA observed S3 and S4 does not have current first aid training on file. At 12:20PM, LPA observed S3 and S4 does not have health screening and TB test results on file. At 12:40PM, LPA observed S5 does not have current annual training on file. At 4:00PM, LPA was informed by administrator that facility has conducted disaster drills and did not document the drills. LPA was not able to verified if disaster drills were completed. At 5:30PM, LPA observed R3 had order for Finasteride 5mg. However, facility does not have the prescription available at the facility. R3 does not have a D/C (discontinue) order for this medications. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with Divina Fernandez. A copy of this report, civil penalty, and appeal rights were provided.
2024-01-19Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
Inspectors investigated complaints about cleanliness, sanitization, resident hygiene, and meal service at the facility. During the inspection, inspectors found resident rooms to be clean and free of odors, and confirmed the facility has housekeeping staff on multiple shifts with rooms cleaned one to two times per week and as needed; the facility also receives deep cleaning every three to four months. The complaints were unsubstantiated, meaning inspectors did not find sufficient evidence to prove the alleged violations occurred.
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Staff does not ensure resident's room is kept clean: S1 stated that the facility has a housekeeper on the day and PM shifts and that rooms are cleaned once to twice a week and as needed. LPA observed all the residents’ rooms to be clean and free of any odors. The staff schedule also included the housekeeping staff. Staff does not ensure facility is properly sanitized: S1 stated the facility gets a deep cleaning (carpets cleaned and furniture sanitized) every 3 – 4 months. The most recent deep cleaning was on 1/14 and 1/15, 2024 This agency has investigated the allegation that staff does not ensure resident's hygiene needs are being met, staff does not ensure resident's room is kept clean and staff does not ensure facility is properly sanitized. staff did not provide adequate meal service to a resident. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.
2023-12-06Annual Compliance VisitNo findings
Plain-language summary
On November 9, 2023, an unannounced inspection was conducted at the facility. A licensing analyst returned on this date to deliver an amended copy of that earlier inspection report to facility management. No new violations or issues were identified during this follow-up delivery visit.
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On this day at around 9:57 am, Licensing Program Analyst arrived unannounced to deliver amended copy of the report previously issued on 11/9/2023. LPA met with Marissa Tangonan. LPA explained to Tangonan the purpose of the visit. LPA provided Tangonan a copy of the report.
2023-11-09Complaint InvestigationUnsubstantiatedNo findings
2023-08-08Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that staff failed to provide adequate meals, supervision, and care; prevented visitors; and restricted residents' use of assistive devices. Investigators interviewed staff and residents, reviewed meal menus and visitor logs, and observed residents using assistive devices during a March 2023 visit; all staff denied the allegations and residents confirmed they received adequate food, were allowed visitors, and could use their devices. No violation was found.
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Continue from Lic9099 Based on interviews conducted, it was alleged that, staff do not ensure meals are made available to resident. LPA confirmed with five (5) staff members and all 5 staff members stated that meals are given to all residents, and room service is also available for residents if residents want to eat in their rooms. LPA confirmed with staff that other food options are given to residents if a resident does not like what is on the food menu for that day. R1, R2, R3, and R4 stated plenty of food is given to residents along with liquids. LPA obtained a food menu for January thought March 2023. Based on interviews conducted, it was alleged that, staff did not provide adequate care and supervision resulting in residents losing weight. LPA confirmed with five (5) staff members, and all 5 staff members stated that residents’ vitals are monitored and checked. A communication is filled out and submitted to the nurse to advise residents’ doctor. Residents PCP, doctors, nurses, and residents’ representative are notified regarding weight loss. Based on interviews conducted, it was alleged that, Staff prevented resident from having visitors. LPA confirmed with five (5) staff members, and all 5 staff members stated that visits are allowed to visit residents. LPA obtained a visitors log from December 2022- February 2023. R1-R4 stated that visits are allowed, and staff allows visitors to come and visit the residents at any time. All visitors have to sign in and out before entering the facility and leaving the facility. Based on interview conducted, Staff prevented resident from using assistive devices. LPA confirmed with five (5) staff members and all 5 staff members stated that residents’ use their assistive device when residents need to. S2 stated to LPA that staff will assist resident sometimes when a resident is walking around the facility with their assistive device. LPA observed residents walking around the facility with assistive devices during visit on 3/17/2023. Based on Interviews, and record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted with ADM, and a copy of this report provided.
2023-07-21Complaint InvestigationSubstantiatedCitation on file
Substantiated — the state found a violation and issued a citation. Full citation details are on file with the state.
5 older inspections from 2021 are not shown above.
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